The Scoop on The SAARDs

By editor | March 6, 2008

SAARDs are very effective medicines that may be just what the doctor ordered for your individual arthritis situation. Some do carry more risk of side effects, however.

Because of the possible toxicity of some of these drugs, you’ll get the best results if you take them exactly as directed, keep notes on how you’re feeling, and report your progress and any problems to your doctor.

Methotrexate. This medication is the “star” of inflammation fighting drugs because of its rapid action and its relative lack of side effects. In the usual doses it only mildly suppresses the immune system and reduces inflammation. Improvement can appear within a month but may take longer. Methotrexate is taken by mouth once a week. Side effects include stomach irritation and inflammation of the lining in your mouth. In a few people, it can cause lung inflammation, bone marrow problems, and serious liver effects. To reduce the risk of liver damage, it’s best to drink no alcohol while on methotrexate. Blood tests will be recommended every four to eight weeks to monitor the health of your liver. And because, like many arthritis medications, methotrexate may potentially cause birth defects, it should be avoided during pregnancy. Very rarely, your doctor might suggest a liver biopsy to check for damage.

A simple dietary strategy can help you: low doses of folic acid, a B vitamin that’s plentiful in fresh spinach, wheat germ, and other foods. In many studies, daily folic acid reduces side effects from methotrexate. In fact, doctors routinely prescribe a folic acid supplement to make sure you’ll be getting enough. Many doctors think methotrexate is the best choice for rheumatoid arthritis when NSAIDs aren’t effective.

Antimalarials. Hydroxychloroquine sulfate (Plaquenil) is the most common SAARD. Around a third of people with rheumatoid arthritis will benefit after using it for three to six months on a dose of 200 to 400 milligrams daily. This SAARD has few side effects; the most serious possible risk, though rare, is damage to the retina of your eye. However, eye damage is uncommon at the usual doses, and because your doctor will recommend that you step up your eye exam schedule to twice a year, it can likely be avoided. Gastrointestinal side effects are also possible.

Corticosteroids. These include cortisone and prednisone and are prescribed for rheumatoid arthritis as well as other inflammatory diseases such as lupus. They rapidly reduce inflammation and suppress the immune system that’s mistakenly causing your body to “attack” itself. If you have such severe rheumatoid arthritis that you can’t get up and go, or you’re waiting for other drugs such as DMARDs to take effect, nothing is more effective at putting you back in motion. Corticosteroids are also advisable in cases of severe internal inflammation, such as vasculitis. The inflammation may return if you stop taking them, however.

Long-term steroid use can cause side effects, most commonly weight gain. That’s because they can give you an incredible appetite for sweets. To prevent the extra pounds, therefore, it’s crucial to weigh yourself daily, avoid excess sugar, and exercise all you safely can.

Along with weight gain, some people on corticosteroids develop a group of symptoms including a round, red face, a rise in blood pressure, and frequent bruising. Other side effects can include stomach ulcers, diabetes, poor wound healing, acne, muscle weakening, and cataracts. There’s also an increased risk of osteoporosis, so taking measures to prevent bone loss is very important.

And if you take these drugs for a long time, your body will stop making its own naturally occurring corticosteroids that battle infection, so your doctor will monitor you for any infection problems. Finally, if you’re on long-term corticosteroids, you should wear a medical alert bracelet in case of an accident, as emergency doctors sometimes need to give replacement steroids.

Sulfasalazine. A new, delayed-release medication for rheumatoid arthritis is sulfasalazine, a combination of a sulfa drug and a salicylate. It suppresses the haywire immune system and helps fight the inflammation that’s already present. Usually your doctor will prescribe two grams daily, and you’ll notice the effect of sulfasalazine in about four weeks. Occasional side effects can include rash, headache, nausea, vomiting, loss of appetite, stomach problems, and low sperm count. Sulfasalazine’s results are considered comparable to those of gold salts and penicillamine. If you take sulfasalazine, your doctor will want you to have frequent complete blood counts.

Gold salts. If NSAIDs don’t help and you can’t take methotrexate, your doctor may try gold salts, which can delay or prevent bone erosion. (They help about 6 people out of 10.) You won’t see the benefits for three to six months, however, so treatment requires patience. You take the gold either by weekly injections into your muscles or by pills twice a day. About a third of those who use gold experience side effects. These can include a rash, inflammation of the mouth, protein in the urine (which may signal kidney problems), and a decrease in both red and white blood cells. Less commonly, gold may also lower platelets in the blood. Gold can also cause diarrhea, plus dizziness and nausea from the injections. Discuss any problems you’re having with your doctor, who will also do regular blood tests to monitor side effects.

Minocycline. This mildly effective agent is used only for mild cases of rheumatoid arthritis. No one is sure just how it works, but it does fight inflammation and apparently inhibits the enzymes that destroy cartilage. The only significant side effect of minocycline is that about 1 in 10 people may feel dizzy after taking it.

Penicillamine. Studies in England have shown that penicillamine helps people with severe rheumatoid arthritis when nothing else does. About half may experience side effects, which can include fever, rash, mouth ulcers, loss of taste, protein in the urine, and low levels of white blood cells and platelets, which your doctor will monitor with blood tests. You should never use penicillamine if you are pregnant, as it can cause birth defects.

Azathioprine (Imuran). This medication works by suppressing the immune reaction that causes inflammation and is often used to prevent the body’s rejection of heart or kidney transplants. It’s not known exactly how it works in rheumatoid arthritis, however. Because azathioprine’s effect on your immunity can make you more vulnerable to infection, it’s generally used when alternatives such as antimalarials and gold do not work. Side effects can include loss of appetite, nausea, and sometimes vomiting, and because it can cause birth defects, it must be avoided during pregnancy. Azathioprine takes several months to be effective.

Cyclosporin (CyA). This drug suppresses the immune system and relieves symptoms of inflammation. It can cause kidney damage, so you can take only low doses, and your doctor must monitor you closely. One study showed that cyclosporin controlled damage to joints better than other treatments: After a year, people treated with CyA had less bone erosion than those who were treated with other DMARDs. Only about 11 percent of the CyA group showed new bone erosion at the end of the year, while the bones of more than half of the people on other medications had eroded.

Cyclophosphamide (Cytoxan). In experimental studies, Cytoxan, a drug used to fight cancer, helped rheumatoid arthritis when nothing else did. Apparently it binds to DNA and RNA and inhibits cell reproduction and that includes the reproduction of haywire immune system cells. Bladder inflammation is a side effect, however, so if you take Cytoxan, be sure to drink lots of water. This drug can damage developing babies, so pregnant women should not take it. Also, Cytoxan use can increase the risk of developing cancer later in life.

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